Pediatric Consultation-Liaison Psychiatry
First year child psychiatry residents complete a four-month rotation on the Pediatric Consultation-Liaison Service. During this time, residents learn to conduct comprehensive consultations to medically ill children and their families in inpatient treatment settings. They learn to evaluate consultation requests, manage the physical, interpersonal, and system boundaries inherent to the psychiatric consultant in a pediatric setting, differentiate pathological from normal behavioral and emotional responses to a medical illness, and work with a multidisciplinary team to devise appropriate treatment plans for children and their families. R esidents provide consultations to any of the child and adolescent inpatients units at Shands Children’s Hospital.
A. Required 3-month rotation occurring in the first year at institution 1 and requiring 25% of the resident’s time
B. Faculty consists of 1 full-time child psychiatrist.
C. Residents see up to 4 new consults per week. All cases are seen and staffed by faculty.
D. The CL service sees 60% female and 40% male patients, with an age range of 6 to 17 years; 80% of referrals are for teenagers, and 20% for younger children. About 85% of patients are Caucasian, 10% African American and the remainder from Asian or Hispanic backgrounds and Diagnoses particular to the C-L populations include: depression in the general medical setting, including suicide/overdose (60%), anxiety in the general medical setting and somatoform disorders (20%), and the remainder at less than 5% include coping with illness, death, dying, and bereavement, delirium/agitation, factitious disorders and malingering, pain, psychiatric manifestations of medical and neurological illness, and psychological factors affecting medical conditions. Of the patients evaluated, about 65% get transferred to the psychiatric inpatient setting, 25% receive specific cognitive-behavioral interventions and 15% receive recommendations for medication management for the referring pediatrician. Brief and supportive therapy modalities are also utilized in a large number of cases.
E. An average caseload for a resident consists of 3 to 4 patients at a given time, which are seen for medication management, psychotherapies and disposition planning.
F. All new and follow up patients are staffed by the faculty and cases are discussed with residents on an individual basis.
G. Following are the goals and objectives for this rotation:
Goals: To be able to provide pediatric psychiatric inpatient consultation for children and adolescents with a range of psychiatric disorders and behavioral health problems at a level consistent with his/her level of training during the first year.
Objectives:
Knowledge: The resident should have a basic fund of knowledge about problems commonly encountered in the area of pediatric consultation and liaison, including:
- To know accurately the role of the C-L psychiatrist
- To know the diagnostic criteria and pathogenesis of conditions commonly encountered in the C-L setting, such as psychosomatic illness; comorbid psychiatric and medical illness; Munchausen’s Syndrome by Proxy; maladaptive reactions to acute and chronic psychosocial stressors; PTSD secondary to medical illness and interventions; grief and bereavement.. To know the relationship of underlying personality and the patient’s previous experiences and the manifestation of physical symptoms.
- To know the principles of treatment of psychiatric patients with medical illness.
- To know about psychiatric sequelae of medical conditions and medical treatments, including psychiatric symptoms arising from medical drugs and metabolic factors.
- To have a clear knowledge of the interaction of psychotropic medications and commonly used medical drugs.
- To have a clear knowledge of the side effects and medical complications of psychotropic drugs.
Skills: The resident should demonstrate the ability to
- Negotiate a consultation request; determining what is needed, in what time frame and who authorized the consultation.
- Manage the physical, interpersonal, and system boundaries inherent to consultation in a medical setting.
- Conduct a comprehensive psychiatric assessment of patients on non-psychiatric wards of a general hospital, including obtaining collateral history from families and other sources.
- Clearly record findings of such an assessment in a manner easily understandable by the referral source. Such record to include a clear formulation of the case, addressing the pathogenesis of the disorder and the role of perpetuating factors.
- Develop expertise in dealing with psychiatric emergencies on medical/surgical wards.
- Apply current knowledge to the interpretation and organization of data gathered through the assessment process.
- Prescribe and carry out biopsychosocial treatments in an effective manner in liaison with medical colleagues and other health professionals in the context of multi-disciplinary framework. Treatment recommendations to focus on acute as well as long-term rehabilitative care and placement considerations as indicated.
- Be sufficiently familiar with medical/surgical conditions frequently encountered in a C-L practice.
- To have a clear rationale for decisions regarding transfer of patients to a psychiatric unit.
Attitudes: The resident should demonstrate
- Commitment to being responsive to requests for consultation.
- Sensitivity to patients and their families when in crisis.
- Respect for the expertise of those requesting consultation.
- Confidence in using a flexible treatment program to accommodate the needs of patients with concurrent medical and psychiatric illness.
- A balanced patient centered approach to patients using a biopsychosocial model and to emphasize integration of this approach into the patient’s overall treatment.
- Ability to liaise with medical colleagues and other members of the health care team (e.g. nursing, psychology, etc.) while providing concurrent care to patients.
- Awareness of counter transference feelings that tend to be evoked when dealing with medically ill patients and to know when to seek supervision around this issue.
